Plasma Fibrinogen Along with Patient-reported Outcome Measures Enhances Management of Polymyalgia Rheumatica: A Prospective Study

Challenges in the diagnosis of polymyalgia rheumatica and related giant cell arteritis

INTRODUCTION

Polymyalgia rheumatica (PMR) has emerged as a relatively common condition in Western countries. Although the diagnosis is relatively straightforward in people over 50 years of age who complain of sudden onset of pain and stiffness in the shoulder and hip girdles along with elevation of biomarkers of inflammation, manifestations of polymyalgia can also occur in the context of different conditions. For this reason, a complete history and examination is required, including looking for symptoms and signs suggestive of giant cell arteritis (GCA).

AREAS COVERED

The review describes when and how to identify PMR, as well as when to suspect the presence of associated GCA or multiple conditions mimicking PMR.

EXPERT OPINION

PMR does not have a specific diagnostic test. For this reason, a thorough clinical history searching for clinical data of GCA is needed. Moreover, the possibility of other diseases mimicking PMR should be considered, particularly when atypical presentation or unusual clinical data are present.

Measurement properties of the PolyMyalgia Rheumatica Activity Score (PMR-AS): a systematic literature review

Objective

To perform a COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) based Systematic Literature Review of measurement properties of the Polymyalgia Rheumatica Activity Score (PMR-AS).

Methods

Pubmed, EMBASE, and CINAHL were broadly searched. English full text articles, with (quantitative) data on at least 5 PMR patients using the PMR-AS were selected. Seven hypotheses for construct validity and three for responsiveness, concerning associations with erythrocyte sedimentation rate, physical function, quality of life, clinical disease states, ultrasound, and treatment response, were formulated. Articles usable to assess - COSMIN based - structural validity, internal consistency, reliability, measurement error, or hypotheses on construct validity or responsiveness were selected and assessed based on COSMIN criteria.

Results

From the 26 articles using the PMR-AS we were able to use 12 articles. Structural validity, internal consistency, construct validity, and responsiveness were assessed in one, two, eight, and three articles respectively. Insufficient evidence was found to confirm structural validity and internal consistency. No data was found on reliability or measurement error. Although 60% and 67% of hypotheses tested for construct validity and responsiveness were confirmed respectively, there was insufficient evidence to meet criteria for good measurement properties.

Conclusion

Whilst there is some promising evidence for construct validity and responsiveness of the PMR-AS, it is lacking for other properties and overall falls short of criteria for good measurement properties. Therefore, further research is needed to assess its role in clinical research and care.

Outcomes Measured in Polymyalgia Rheumatica and Measurement Properties of Instruments Considered for the OMERACT Core Outcome Set: A Systematic Review

OBJECTIVE

To systematically identify the outcome measures and instruments used in clinical studies of polymyalgia rheumatica (PMR) and to evaluate evidence about their measurement properties.

METHODS

Searches based on the MeSH term "polymyalgia rheumatica" were carried out in 5 databases. Two researchers were involved in screening, data extraction, and risk of bias assessment. Once outcomes and instruments used were identified and categorized, key instruments were selected for further review through a consensus process. Studies on measurement properties of these instruments were appraised against the COSMIN-OMERACT (COnsensus-based Standards for the selection of health Measurement Instruments-Outcome Measures in Rheumatology) checklist to determine the extent of evidence supporting their use in PMR.

RESULTS

Forty-six studies were included. In decreasing order of frequency, the most common outcomes (and instruments) used were markers of systemic inflammation [erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)], pain [visual analog scale (VAS)], stiffness (duration in minutes), and physical function (elevation of upper limbs). Instruments selected for further evaluation were ESR, CRP, pain VAS, morning stiffness duration, and the Health Assessment Questionnaire. Five studies evaluated measurement properties of these instruments, but none met all of the COSMIN-OMERACT checklist criteria.

CONCLUSION

Measurement of outcomes in studies of PMR lacks consistency. The critical patient-centered domain of physical function is poorly assessed. None of the candidate instruments considered for inclusion in the core outcome set had high-quality evidence, derived from populations with PMR, on their full range of measurement properties. Further studies are needed to determine whether these instruments are suitable for inclusion in a core outcome measurement set for PMR.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are associated with disease activity in polymyalgia rheumatica

Background

The neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and monocyte‐to‐lymphocyte ratio (MLR) are indicators of systemic inflammation and are useful as markers in systemic rheumatic diseases. In this study, we compared the NLR, PLR, and MLR among patients with polymyalgia rheumatica (PMR) and rheumatoid arthritis (RA), and explored possible associations with clinical features, disease activity, and prognosis in patients with PMR.

Methods

The study enrolled 94 patients with PMR and 242 patients with RA who were initially diagnosed at the rheumatology clinic of a university‐based tertiary hospital. Symptoms, physical examination, and medical histories were collected with the results of laboratory tests.

Results

Neutrophil‐to‐lymphocyte ratio (4.5 ± 3.3 vs 2.8 ± 1.8), PLR (222.7 ± 115.5 vs 159.7 ± 78.1), and MLR (0.4 ± 0.3 vs 0.3 ± 0.2) were higher in patients with PMR compared with patients with RA (all P < .001). NLR, PLR, and MLR were correlated with specific laboratory values, including CRP and albumin, in patients with PMR. After disease activity resolved, NLR (2.95 ± 2.32, P < .001), PLR (137.5 ± 82.3, P < .001), and MLR (0.26 ± 0.16, P < .001) decreased significantly. By comparing patients according to the disease course, swollen joint counts were higher in the chronic course group compared with the remission group (P = .03), while the NLR, PLR, and MLR were similar.

Conclusions

Neutrophil‐to‐lymphocyte ratio, platelet‐to‐lymphocyte ratio, and monocyte‐to‐lymphocyte ratio levels were associated with disease activity and specific clinical features, although they could not predict prognosis in patients with PMR.

Outcome Measures in Polymyalgia Rheumatica. A Systematic Review

Objective.

To identify the instruments used to assess polymyalgia rheumatica (PMR) in published studies.

Methods.

A systematic literature review of clinical trials and longitudinal observational studies related to PMR, published from 1970 to 2014, was carried out. All outcome and assessment instruments were extracted and categorized according to core areas and domains, as defined by the OMERACT (Outcome Measures in Rheumatology) Filter 2.0.

Results.

Thirty-five articles (3221 patients) were included: 12 randomized controlled trials (RCT); 3 nonrandomized trials; and 20 observational studies. More than 20 domains were identified, measured by 29 different instruments. The most frequently used measures were pain, morning stiffness, patient global assessment and physician global assessment, erythrocyte sedimentation rate, and C-reactive protein. The definition of outcomes varied considerably between studies.

Conclusion.

The outcome measures and instruments used in PMR are numerous and diversely defined. The establishment of a core set of validated and standardized outcome measurements is needed.

Polymyalgia rheumatica: 125 years of progress?

OBJECTIVES

On the 125th anniversary of the first recognised publication on polymyalgia rheumatica, a review of the literature was undertaken to assess what progress has been made from the point of view of the clinical care of affected patients.

METHODS

The authors searched Medline and PubMed using the search terms 'polymyalgia rheumatica', 'giant cell arteritis' and 'temporal arteritis'. As much as possible, efforts were made to focus on studies where polymyalgia rheumatica and giant cell arteritis were treated as separate entities. The selection of articles was influenced by the authors' bias that polymyalgia rheumatica is a separate clinical condition from giant cell arteritis and that, as yet, the diagnosis is a clinical one. Apart from the elevation of circulating acute phase proteins, which has been recognised as a feature of polymyalgia rheumatica for over 60 years, the diagnosis receives no significant help from the laboratory or from diagnostic imaging.

RESULTS

This review has shown that, following the recognition of polymyalgia as a distinct clinical problem of the elderly, the results of a considerable amount of research efforts including those using the advances in clinical imaging technology over the past 60 years, have done little to change the ability of clinicians to define the disease more accurately. Since the introduction of corticosteroids in the 1950s, there has been also very little change in the clinical management of the condition.

CONCLUSIONS

Polymyalgia rheumatica remains a clinical enigma, and its relationship to giant cell arteritis is no clearer now than it has been for the past 125 years. Diagnosing this disease is still almost exclusively dependent on the clinical acumen of a patient's medical attendant. Until an objective method of identifying it clearly in the clinical setting is available, uncovering the aetiology is still unlikely, and until then, preventing the pain and stiffness of the disease while avoiding the problems of prolonged exoposure to corticosteroids is likely to remain elusive or serendipitous.